Download Statement of Financial Responsibility

R. BYRON OSBORNE, M.D.
JULIAN C. FAGERLI, M.D.
MARK H. PASSARELLA, M.D.
Urological Associates, LTD.
CLAIBORNE G. WHITWORTH IV, M.D.
JAMES I. MASLOFF, M.D. (retired)
WILLIAM A. ORR, M.D. (retired)
155 Riverbend Drive, Charlottesville, VA 22911-8641 Phone (434) 295-0184 Fax (434) 295-2463
June 27, 2017
Thank you for making an appointment with Urological Associates, Ltd. Please complete the following
paperwork and bring it with you to your appointment.
If you have any questions please feel free to call 295-0184 or 295-0185. Please bring your insurance
card(s) and verify your referral when required.
Thank you,
Urological Associates, Ltd
Welcome to Urological Associates, Ltd.
Patient Information
Chart #
Date
Doctor
Patient
Patient SS #
Address
City, State, Zip
Age
Birthdate
Sex
Occupation
Marital Status
Employer
If minor Parent’s name
Employer
Spouse’s Name
Work Phone #
Birthdate
SS #
Referring Physician
Phone #
Phone Numbers
Home Phone
Work Phone
Cell Phone _________________________ Email ___________________________________________
IN CASE OF EMERGENCY, CONTACT
Name
Home Phone
Relationship
Work Phone
Insurance (This information is required)
Policy holder’s
name
Relation to the patient
Birthdate
Primary Insurance
SS #
Secondary Insurance
Name
Policy #
Address
Name
Policy #
Address
City, State, Zip
City, State, Zip
Today’s Date
Name
Chart #
Date of Birth
History of Present Illness (All information is strictly confidential)
What is the main reason for your visit today? _____________________________________________________
Location of the problem
Abdomen
Back
Bladder
Prostate
Other ____________________________________________________________________________________
On a scale of 1-10 with 10 being the most severe, circle the number that best describes the problem?
1
2
3
4
5
6
7
8
9
10
When did you first notice the problem?
2 days ago
2 weeks ago
1 month ago
Other ____________________________________________________________________________________
Does anything help of make the pain worse?
Moving around
Standing up
Lying on my side
Other ____________________________________________________________________________________
How long does the problem last?
30 minutes
1 hour
It is always there
Other ____________________________________________________________________________________
Is there anything else occurring at the same time?
Yes
No
If Yes. Please explain
Nausea, Rash, Headaches, Other___________________________________________________________
Is the problem constant or variable?
Dull then Sharp
Very sharp then leaves
Always there
Other _____________________________________________________________________________________
Does the problem interfere with your normal daily functions?
Yes
No
If Yes. Please explain
__________________________________________________________________________________________
Men Only
Are you satisfied with your erections?
Yes
No
Medical History
List any medical problems _______________________________________________________________________
_____________________________________________________________________________________________
List previous surgery ___________________________________________________________________________
_____________________________________________________________________________________________
List all medications and dosage you are currently taking _______________________________________________
_____________________________________________________________________________________________
Do you take aspirin or motrin on a daily basis
Yes
No
List any drug allergies __________________________________________________________________________
Have you ever smoked?
Do you drink alcohol?
Yes
Yes
No
No
If yes. How much & how often? _______________________________
If yes, how much & how often? _______________________________
Preferred Pharmacy ___________________________________________________________________________
Family History
Has anyone in your immediate family (mother, father, siblings, grandparents, etc………)ever been diagnosed with:
Diabetes
YES
NO
Heart Disease
YES
NO
Cancer
YES
NO
Type________________________________
Kidney Stones
YES
NO
Relation_______________________________________
Relation_______________________________________
Relation_______________________________________
Relation_______________________________________
Review of Systems
Do you now or have you had any problems related to the following systems? Circle Yes or No
Constitutional Symptoms
Integumentary
Fever
Y
N
Skin rash
Y
Chills
Y
N
Boils
Y
Headache
Y
N
Persistent itch
Y
Other _________________
Other ____________________
Eyes
Musculoskeletal
Blurred Vision
Y
N
Joint pain
Y
Double Vision
Y
N
Neck Pain
Y
Pain
Y
N
Back pain
Y
Other __________________
Other ____________________
Allergic / Immunologic
Hay Fever
Y
Drug Allergies
Y
Other __________________
Neurological
Tremors
Y
Dizzy spells
Y
Numbness/tingling
Y
Other __________________
Endocrine
Excessive thirst
Y
Too hot/cold
Y
Tired/sluggish
Y
Other __________________
Gastrointestinal
Abdominal Pain
Y
Nausea / Vomiting
Y
Indigestion/heartburn Y
Other __________________
Cardiovascular
Chest pain
Y
Varicose Veins
Y
High blood pressure Y
Other __________________
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Ear/Nose/Throat/Mouth
Ear Infection
Y
N
Sore Throat
Y
N
Sinus Problems
Y
N
Other ____________________
Genitourinary
Urine retention
Y
N
Painful urination
Y
N
Urinary Frequency
Y
N
Other ____________________
Respiratory
Wheezing
Y
N
Frequent Cough
Y
N
Shortness of Breath
Y
N
Other _____________________
Hematologic/lymphatic
Swollen glands
Y
N
Blood clotting problem Y
N
Other _____________________
Psychologic
Are you generally satisfied with your life Y N
Do you feel severely depressed
Y N
Have you considered suicide
Y N
Other ______________________
Signatures
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his/her
staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient Signature _________________________________________________ Date __________________________________
Physician Signature _________________________________________________ Date ________________________________
Urological Associates, Ltd. Financial Responsibility, Assignment of Benefits, and
Patient Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Healthcare Operations
I, ____________________________________, hereby consent to treatment by Urological Associates, Ltd. Physicians and their assistants
and accept responsibility for such fees for such medical services not covered by my insurance. I also understand that as part of my heath care,
Urological Associates Ltd. Originates and maintains paper and/or electronic records describing my health history, symptoms, examination
and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:
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A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care,
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third party payer can verify that services billed were actually provided, and
A tool for routine healthcare operations such as assessing quality and review the competence of healthcare professionals
I understand and have been provided with a Notice of Information Practices (available upon request) that provides a more complete
description of information uses and disclosures. I understand that I have the following rights and privileges:
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The right to review the notice prior to signing this consent
The right to object to the use of my health information for directory purposes, and
The right to request restrictions as to how my heath information my be used or disclosed to carry out treatment, payment or heath
care operations
I understand that Urological Associates, Ltd. is not required to agree to the restrictions requested. I understand that I may revoke this consent
in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this
consent or revoking this consent, this organization may refuse to treat me as permitted by section 164.506 of the Code of Federal Regulations.
I wish to have the following restrictions to the use or disclosure of my heath information:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I understand that as part of this organization’s treatment, payment, or heath care operations. It may become necessary to disclose my
protected heath information to another entity, and I consent to such a disclosure for these permitted uses, including disclosure via fax.
Statement of Accidental Body Fluid Exposure
I understand that if healthcare workers are accidentally exposed to my blood or body fluids in the course of providing healthcare to me. I
agree to have my blood tested for any infectious disease, which might be transmitted to them through this exposure including HIV/AIDS and
hepatitis.
Statement of Financial Responsibility
I understand that payment is due at the time of service. I herby authorize the release of any information necessary for filing a claim for
payment with my insurance company of records. I also authorize payment for services rendered be made directly to the physician(s)
providing the service. This authorization is valid for current and subsequent treatment unless I submit a written revocation. I will advise
Urological Associates, Ltd. of any changes in insurance coverage. Outstanding debt past 90 days will be referred to a collection agency.
Collection fees of 35% will be added to the outstanding debt as well as all attorney fees incurred during the collection process.
Statement to permit payment of Medicare/Medicaid benefits to provider(if applicable)
I request that payment of authorized Medicare/Medicaid benefits be made on my behalf to Urological Associates, Ltd. for any services
furnished me by that Provider. I understand my signature requests that payment be made and authorizes release of medical information
necessary to pay the claim. In Medicare/Medicaid assigned cases, the physician or supplier agrees to accept the charges determination of the
Medicare/Medicaid carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services.
Coinsurance and the deductible are based upon the charge determination of the Medicare/Medicaid carrier.
Statement to permit payment of Medigap benefits to provider (if applicable)
I request that payment of authorized Medigap benefits be made on my behalf to the Provider for any medical services furnished to me by that
Provider.
I fully understand and accept the terms of this consent.
_________________________________________________________
Patient’s Signature (Parent’s if Minor)
_______________________________________
Date